Introduction
A stuffed-up nose adversely affects a child's development. It has also been reported that nasal obstruction has an important effect on facial growth and development, especially in the first decade of life.Reference Grymer and Bosch1,Reference Yildirim and Okur2 Therefore, determining nasal obstruction in children and informing their families about its potential harmful effects may be important to prevent developmental problems with regard to facial growth, snoring, upper airway infections and respiratory problems that can result from nasal obstruction.
The aetiology of nasal obstruction is associated with developmental problems and trauma. Nasal obstruction causes impaired nasal breathing and several pathologies, such as developmental disorders, frequent infections, mental disorders and olfactory and gustatory disorders, that may develop as a result of impairment of respiration, which is one of the most significant functions of the nose.Reference Fidan, Fidan, Ak and Sütbeyaz3 Recent studies have reported nasal obstruction as a cause of sleep disturbance.Reference Meen and Chandra4,Reference Pevernagie, De Meyer and Claeys5 Patients may be asymptomatic during the daytime but present with complaints of nasal obstruction that are particularly troublesome at night.Reference Pevernagie, De Meyer and Claeys5 It is known that the quality of both sleep and life is impaired in the presence of nasal obstruction. However, there are few studies and publications regarding neuropsychiatric evaluations of this disorder and the interventions it may require.
The present study mainly evaluated the psychological status and personality profiles of patients diagnosed with unilateral or bilateral complete nasal obstruction based on the hypothesis that nasal obstruction may affect psychological status because of impaired sleep and daytime irritability. In the literature on the relationship between psychological status and nasal obstruction, there are few studies in English.
Materials and methods
The present study was performed at a tertiary referral centre in the clinics of the Departments of Otorhinolaryngology and Psychiatry, according to the Helsinki declaration (World Medical Association 2010). All volunteers were included in the study with the approval of the university's ethics committee and in accordance with the guidelines of the National Health and Medical Research Committee. All volunteers were provided with information about the evaluation, and written informed consent was obtained prior to the study.
The study's design was prospective, observational, controlled and single-blinded, and it included 49 consecutive patients (20‒42 years old) with unilateral or bilateral complete nasal obstruction who presented to the otorhinolaryngology clinic. Patients whose chief complaint was ‘nasal obstruction’ (caudally complete nasal septal deviation, bilaterally or unilaterally) were included, and diagnoses were confirmed by endoscopic examination using a 0° 4.0-mm nasal endoscope.
The study's exclusion criteria included patients who had nasal polyps, chronic sinusitis or allergic rhinitis. Likewise, any history of psychiatric disease or use of psychiatric medications excluded a participant from the study.
The patients were compared with a group of healthy controls that included 41 volunteers with similar demographic characteristics but no nasal obstruction. These volunteers were questioned about any history of other diseases or the use of medications.
Data collection instruments
A sociodemographic data form was prepared, and volunteers were questioned about age, gender, history of nasal trauma and level of education.
Personality belief questionnaire
Originally developed and introduced by Beck TA et al., the Personality Belief Questionnaire includes an equal number of items representing avoidant, dependent, obsessive compulsive, histrionic, passive aggressive, narcissistic, paranoid, schizoid and antisocial personality disorders.Reference Fournier, Derubeis and Beck6 The scale contains the following instructions: ‘Please read the statements below and rate how much you believe each one. Try to judge how you feel about each statement most of the time’. The scale asks respondents to circle a number reflecting how much they believe a statement. The options are 0 (‘I don't believe it at all’), 1 (‘I believe it slightly’), 2 (‘I believe it moderately’), 3 (‘I believe it very much’) and 4 (‘I believe it totally’). The questionnaire was translated into Turkish, followed by an appropriate validity and reliability study.Reference Türkçapar, Örsel, Uğurlu, Sargın, Turhan and Akkoyunlu7
Beck Anxiety Inventory
This inventory was developed by Beck et al. in 1988Reference Beck and Steer8 and measures the severity of an individual's anxiety symptoms. It asks about subjective anxiety and physical symptoms using 21 questions that patients answer using a Likert-type scale ranging from 0‒3. Its point range is from 0‒63. The higher the total score, the more severe the individual's anxiety. The Turkish validity and reliability study for the inventory was conducted by Ulusoy et al.Reference Ulusoy, Şahin and Erkmen9
Beck Depression Inventory
The Beck Depression Inventory aims to objectively evaluate the symptoms of depression rather than diagnosing it.Reference Beck and Steer10 The inventory consists of 21 questions, each of which has 4 possible answers that are scored from 0‒3. The total score demonstrates the severity of depression. The validity and reliability study for this inventory was conducted by Hisli.Reference Hisli11
Spielberger's State–Trait Anxiety Inventory I‒II
This inventory was developed by Spielberger et al. and is composed of two subscales, state and trait, each of which consists of 20 questions.Reference Spielberger, Gorssuch, Lushene, Vagg and Jacobs12,Reference Spielberger, Sydeman and Maruish13 The State–Trait Anxiety Inventory I identifies how an individual feels about himself or herself at a certain time and under particular conditions. The State–Trait Anxiety Inventory II scale identifies how an individual feels about himself or herself irrespective of the state and conditions he or she is involved in. It is a simple self-inventory. It was adapted to Turkish by Öner and LeCompte.Reference Öner and Lecompte14 The personality questionnaires were evaluated by a psychiatrist, and the scores were statistically compared.
Statistical analysis
The statistical data were analysed using SPSS® (version 16.0) statistical analysis software. Descriptive statistics were given as the mean and standard deviation. Normal distribution was assessed using a Kolmogorov–Smirnov test. For non-normally distributed parameters, non-parametric tests were used. In order to establish significance in the comparison of quantitative data between the groups, a Kruskal–Wallis test was performed. In order to compare the groups pairwise, a Mann–Whitney U test was used. A value of p less than 0.05 was considered statistically significant.
Results
The mean age of patients with unilateral or bilateral complete nasal obstruction was 31.4 ± 11.1 years, whereas in the healthy controls, it was 33.4 ± 10.2 years. The groups were similar in terms of demographic data and education levels. In both groups, the highest level of education obtained by the largest number of participants was elementary school, followed by high school and university (Table 1).
Table 1. Education profiles of the groups
S = unilateral or bilateral complete nasal obstruction; HC = healthy control group
Patients with unilateral or bilateral complete nasal obstruction had higher scores on all personality traits compared with the healthy controls (Table 2). Although all personality scores were higher in patients, the only differences that were statistically significant were the dependent, antisocial and avoidant personality trait scores (p = 0.042, p = 0.014 and p = 0.05, respectively) (Figure 1, Table 2). Patients with unilateral or bilateral complete nasal obstruction had scores that were higher than those of the healthy controls on all the depression and anxiety evaluation scales except the Beck Anxiety Inventory, although these scores were not significantly higher (Table 3).
Table 2. Comparison of psychological status
* Statistically significant p < 0.05. S = unilateral or bilateral complete nasal obstruction; SD = standard deviation; HC = healthy control group
Figure 1. Comparison of psychological status. Asterisk indicates statistically significant difference (p < 0.05).
Table 3. Comparison of anxiety and depression levels
*Statistically significant p < 0.05. S = unilateral or bilateral complete nasal obstruction; SD = standard deviation; HC = healthy control group. STAIX = State–Trait Anxiety Inventory
Discussion
The present study mainly evaluated the psychological status and depression and anxiety levels of patients with diagnosed nasal obstruction based on the belief that nasal obstruction may affect psychology because of impaired sleep and daytime irritability.
A study by Ekici et al. assessed 97 patients with sleep apnoea, comparing them in terms of personality traits to patients in similar age groups who snored. Sleep apnoea patients were significantly more hypochondriacal, and higher scores on psychopathic deviation and personality traits were also observed.Reference Ekici, Ekici, Oğuztürk, Karaboğa, Cimen and Senturk15
• Nasal obstruction has been reported to have an important effect on facial growth and development, especially in the first decade of life
• The present study mainly evaluated the psychological status and personality profiles of patients diagnosed with unilateral or bilateral complete nasal obstruction
• Patients with unilateral or bilateral complete nasal obstruction had higher psychiatric symptom scores compared with healthy controls
• Nasal obstruction may affect psychological status because of impaired sleep and daytime irritability
• More attention should be paid to the psychological status of patients with nasal deformities
Every individual is unique in terms of qualities and traits. Our personalities define our thoughts, feelings and behaviour in terms of how we think and feel, the decisions we make and the actions we take. Personality is the determining factor in how we live our lives. Psychological status is determined, in part, by our genetics as well as our environment. People with obsessive compulsive (anankastic) and anxious or dependent personality disorders are often viewed as anxious and fearful. These individuals are excessively afraid of social relations and have feelings of tension, apprehension, insecurity and inferiority. Fidan et al. studied the psychiatric symptoms of patients with nasal septum deviation, assessing somatisation, obsession, interpersonal sensitivity, depression, anxiety, phobic anxiety, hostility, paranoid thoughts, psychotism and quality of life. They found that psychiatric symptoms were significantly more pronounced in patients with septal deviations.Reference Fidan, Fidan, Ak and Sütbeyaz3
Vamanshankar et al. researched the personality traits of patients with allergic rhinitis and the correlation between its severity and personality. Using the International Personality Disorder Examination questionnaire, they found that the C-type personality was more frequent in patients with allergic rhinitis and that dominant anxious traits were more pronounced compared with healthy controls.Reference Vamanshankar, Hegde, Chaturvedi, Pratibha, Ross, Nayar and Parameshwaran16,Reference Akkoca, Oğuz, Ünlü, Aydın, Ozdel and Kavuzlu17
Although it has been acknowledged in the literature that patients diagnosed with nasal obstruction have a lower quality of sleep and a lower quality of life, there is limited data about the relationship between psychological status and nasal obstruction and about how poor mental health may result from negative emotions because of obstructed airflow.Reference Strazdins, Nie, Ramli, Palesy, Christensen and Marcells18
Aikens and Mendelson found that compared with patients with primary snoring, patients with sleep apnoea had significantly higher absolute scores and nearly twice the rate of clinical elevation on scales of both depression and hypochondriasis. They concluded that sleep apnoea patients had relatively more inactivity, anergia, guilt, pessimism and low self-esteem accompanied by dominant somatic concerns.Reference Aikens and Mendelson19
Patients with unilateral or bilateral complete nasal obstruction had higher psychiatric symptom scores for all personalities (Table 2). Although all scores were higher, only the dependent and antisocial personality traits were significantly higher compared with the healthy controls (Table 2). It would not be wrong to state that unilateral or bilateral complete nasal obstruction are related to higher psychiatric symptom scores. Patients with nasal obstruction had higher scores indicating depression or anxiety compared with healthy controls, although the scores were not significantly higher (Table 3). Studies have shown that nasal surgery, such as septoplasty or septorhinoplasty, improves scores regarding nasal symptoms and nasal obstruction. Patients with psychiatric symptoms can be evaluated from an otorhinolaryngological perspective. Patients with antisocial and dependent personality status can benefit from nasal surgery. Prospective studies with longitudinal designs should be designed for further research.
Conclusion
Patients with unilateral or bilateral complete nasal obstruction had higher psychiatric symptom scores compared with healthy controls, although the differences were not statistically significant, except for the scores regarding dependent and antisocial personality traits. The psychological conditions of patients with structural deformities that cause nasal obstruction may be affected by these obstructions, and appropriate nasal treatment should be provided to improve their symptoms and quality of life.
Competing interests
None declared
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